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Reference Right Atrial Dimensions and Volume Estimation by Steady State Maceira et al. Journal of Cardiovascular Magnetic Resonance 2013, 15:29 http://www.jcmr-online.com/content/15/1/29 RESEARCH Open Access Reference right atrial dimensions and volume estimation by steady state free precession cardiovascular magnetic resonance Alicia M Maceira1, Juan Cosín-Sales2, Michael Roughton3, Sanjay K Prasad4 and Dudley J Pennell4* Abstract Background: Cardiovascular magnetic resonance (CMR) steady state free precession (SSFP) cine sequences with high temporal resolution and improved post-processing can accurately measure RA dimensions. We used this technique to define ranges for normal RA volumes and dimensions normalized, when necessary, to the influence of gender, body surface area (BSA) and age, and also to define the best 2D images-derived predictors of RA enlargement. Methods: For definition of normal ranges of RA volume we studied 120 healthy subjects (60 men, 60 women; 20 subjects per age decile from 20 to 80 years), after careful exclusion of cardiovascular abnormality. We also studied 120 patients (60 men, 60 women; age range 20 to 80 years) with a clinical indication for CMR in order to define the best 1D and 2D predictors of RA enlargement. Data were generated from SSFP cine CMR, with 3-dimensional modeling, including tracking of the atrioventricular ring motion and time-volume curves analysis. Results: In the group of healthy individuals, age influenced RA 2-chamber area and transverse diameter. Gender influenced most absolute RA dimensions and volume. Interestingly, right atrial volumes did not change with age and gender when indexed to body surface area. New CMR normal ranges for RA dimensions were modeled and displayed for clinical use with normalization for BSA and gender and display of parameter variation with age. Finally, the best 2D images-derived independent predictors of RA enlargement were indexed area and indexed longitudinal diameter in the 2-chamber view. Conclusion: Reference RA dimensions and predictors of RA enlargement are provided using state-of-the-art CMR techniques. Keywords: Magnetic resonance, Heart, Right atrial volume, Dimensions, Reference values Background the other, so their combined enlargement may better ex- Right atrial (RA) enlargement may occur in numerous press more remarkable structural remodeling and, more conditions including congenital heart disease, acquired importantly, the combination of these conditions might valvular disease, pulmonary disorders, and heart failure. be a better prognostic indicator of AF recurrence than Remodeling of the RA has also been reported in patients either alone. Another potential clinical value of RA with paroxysmal atrial fibrillation (AF) [1-3], and recent measurement, since RA size is at least partially deter- data have shown that both left atrial (LA) and RA re- mined by the same factors that affect diastolic right ven- modeling are equally associated with recurrence of AF tricular (RV) filling, is its ability to act as an early after cardioversion [4]. Interestingly, RA and LA remod- marker of RV dysfunction, which often precedes systolic eling may coexist because one predisposes the heart to dysfunction in a variety of conditions affecting the RV. Furthermore, it may provide significant prognostic infor- mation in patients with chronic systolic heart failure [5] * Correspondence: [email protected] 4Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, Sydney and pulmonary hypertension [6,7]. Street, London SW3 6NP, United Kingdom Full list of author information is available at the end of the article © 2013 Maceira et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Maceira et al. Journal of Cardiovascular Magnetic Resonance 2013, 15:29 Page 2 of 10 http://www.jcmr-online.com/content/15/1/29 Atrial remodeling is most accurately estimated by Royal Brompton Hospital, and all subjects gave written measuring atrial volume, but in current clinical practice informed consent. this is not routinely performed. Cardiovascular magnetic resonance (CMR) is the gold standard technique for CMR measurement of ventricular dimensions and function CMR was performed with 1.5 T scanners (Siemens with reference ranges established from the Steady State Sonata and Avanto) using front and back surface coils Free Precession (SSFP) technique [8,9], and this has also and retrospective ECG triggering for capture of the en- been reported for the left atrium [10]. Some studies on tire cardiac cycle including diastole. All CMR scans were RA reference values have been published [11-13], but performed by the same operator. SSFP end-expiratory RA dimensions have not been extensively studied with breath-hold cines were acquired in the two (left and CMR as well as the systematic analysis of the influences right chambers) and four chamber views, with subse- of age, gender and body surface area (BSA). Therefore, quent contiguous short-axis cines from the atrioven- the aim of this study was to establish SSFP based refer- tricular (AV) ring to the base of the atria. Slice thickness ence values in normal subjects for RA dimensions nor- was 5 mm with no gap between slices. The temporal malized for independent influences such as gender, body resolution was 21 ±1 ms. Sequence parameters included surface area and age when required. We also aimed to repetition time/echo time of 3.2/1.6 ms, in-plane pixel determine the best predictors of right atrial enlargement size of 2.1 × 1.3 mm, flip angle 60º, and acquisition time among 1D and 2D parameters, and relate RA volume to of typically 18 heartbeats. RA diameters and areas, as these are easily obtained in the clinical setting. CMR analysis Analysis was performed with a personal computer and Methods semi-automated software (CMRtools, Cardiovascular Normals and patients Imaging Solutions, London, UK). In all subjects (healthy For definition of normal ranges of RA dimensions we controls and patients) RA maximum volume was mea- studied 120 subjects, with 10 men and 10 women in sured as well as maximum diameters and areas, mea- each of 6 age deciles from 20 to 80 years. This cohort of sured in the 42-chamber and right 2-chamber views. healthy subjects has been used for defining left and right Atrial volume analysis included 2 steps: First, delineation ventricular and LA reference dimensions. Their baseline of the atrial endocardial border in all planes in all car- characteristics have been published previously [8]. In diac phases. Second, the systolic descent and twist of the brief, all subjects were normotensives (hypertension de- tricuspid valve was calculated from tracking of the valve fined as systolic blood pressure ≥ 140 mmHg and/or dia- motion on the long axis cines, and used to correct stolic blood pressure ≥ 90 mmHg), asymptomatic, with for increase in atrial volume due to AV ring descent no known risk factors or history of cardiac disease, and (Figure 1). We included the atrial appendage and ex- with normal physical examination and electrocardiogram cluded the cava veins. Other approaches are possible, (ECG). Height, weight, blood pressure, total cholesterol, but the arguments for and against are not decisive. All HDL and B-natriuretic peptide were measured in all. diameters and areas derived from 2D images were mea- BSA was calculated according to the Mosteller formula sured in the phase of the corresponding cine sequences [14]. The coronary artery disease risk over 10 years was at which the atrial size and volume measurements were calculated [15]. BNP levels were 2.5 ±2.1 pg/mL (range at a maximum. The longitudinal diameter was measured 0.5 – 12.0), and all were in the normal range (<100 pg/ form the midpoint of the line between the lateral mL) [16]. Therefore, as far as it was possible to ascertain and septal (or superior and inferior in the 2-chamber with conventional noninvasive techniques, all the appar- view) insertion of the tricuspid valve to the roof of ently healthy volunteers had a normal cardiovascular the right atrium. Transverse diameter was measured per- system with no high blood pressure and no evidence of pendicular to the midpoint of the longitudinal diameter heart failure. In a second step, and in order to define the (Figure 2). best 1D and 2D predictors of RA enlargement, a group of 120 patients (60 men and 60 women, age range 20– Statistical analysis 80) that were referred to CMR for clinical reasons, who This was carried out with the statistical software SPSS Sta- were in sinus rhythm and who agreed to participate in tistics 17.0 (IBM, United States). All atrial parameters the study, were included. The main reasons for referral were found to satisfy a normal distribution using the to CMR have been published elsewhere [10] and are Kolmogorov-Smirnov test and summary data for these briefly summarized in Table 1. Research was in compli- variables are presented as mean ± SD. Intra and ance with the Helsinki Declaration. The study was ap- interobserver reproducibility were tested in 50 subjects proved by the institutional Ethics Committee of the belonging to the cohort of healthy subjects. Simple linear Maceira et al. Journal of Cardiovascular Magnetic Resonance 2013, 15:29 Page 3 of 10 http://www.jcmr-online.com/content/15/1/29 Table 1 Baseline characteristics of the healthy subjects and the patient group (mean ± SD) Healthy
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